M. K. Khoury1,2, M. L. Pickett1, T. Hranjec1, S. A. Hennessy1, M. W. Cripps1 1University Of Texas Southwestern Medical Center,Surgery,Dallas, TX, USA 2University Of Wisconsin,Surgery,Madison, WI, USA
Introduction:
A necrotizing soft tissue infection (NSTI) is a life-threatening surgical emergency associated with significant morbidity and mortality. These patients often require multiple debridements, intensive care, and complex wound management. Therefore, it is thought that NSTIs are best treated in large tertiary centers. While regionalization of care for emergency general surgery patients has been a topic of debate, there is evidence that shows it can improve outcomes. In this study, we used NSTIs as a surrogate for patients in need of higher level of care and examined whether transfer status affected outcomes.
Methods:
We conducted a retrospective review of patients with an International Classification of Disease (ICD) code associated with necrotizing fasciitis from 2012-2015 at two tertiary care institutions. Patients transferred to a tertiary center (Transfer-NSTI) were compared to those who were primarily treated at a tertiary center (Primary-NSTI). These patients were compared on demographics, comorbidities, surgical debridement, and outcomes. The primary endpoint was in-hospital mortality. Early transfer was defined ≤1 hospital day at the OSH, while late transfer was defined as >1 hospital day at the OSH. Patients were compared by univariate analysis using Wilcoxon rank sum, Chi-square, and Fisher’s exact tests where appropriate.
Results:
A total of 138 NSTI patients were identified with an overall mortality rate of 20.3%. Of these, 99 (71.8%) were Primary-NSTI patients and 38 (28.2%) were Transfer-NSTI patients. The mortality rate was significantly higher for Transfer-NSTI patients compared to Primary-NSTI patients (33.3% versus 15.2%, p=0.032). Transfer-NSTI patients had significantly higher rates of mechanical ventilation (68.4% versus 46.4%, p=0.019). There was no difference in mortality in Transfer-NSTI patients that were debrided prior to transfer than those who were not debrided (36.0% versus 25.0%, p=0.71.). There was also no difference in mortality for patients who were transferred early (30%) versus those who were transferred late (38.1%).
Conclusion:
Regionalization of care has shown significant improvement in survival for injured patients and many believe the same will be true for emergency general surgery. Using NSTI as a surrogate for patients in need of higher level of care, we identified that primary treatment of NSTI at a large tertiary has significantly better outcomes than those who were transferred. However, large multi-institutional studies are needed to identify risk factors for morbidity and mortality in transfer patients to improve outcomes.